• Behavioral Health Reviewer- Fully Licensed (LMSW / LPC)

    Job Location US-MI-Detroit
    Job ID
    Utilization Management
    Business Line
    CMC Corporate
  • Overview

    Who we are:

    Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.


    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.


    Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.


    A Day in the Life of a Behavioral Health Reviewer (LMSW / LPC):


    This position requires a fully licensed professionaly (LMSW / LPC) who will work  collaboratively with the members of the Behavioral Health Case Management team to perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services requiring clinical review including all levels of appeal requests.


    • Demonstrate consistent ability to collect pertinent documentation and conduct inpatient Psychiatric review applying appropriate criteria, which may include national standardized criteria, local plan rules and guidelines, benefit certificates and other resources as indicated, while at the same time utilizing sound clinical judgment
    • Complete authorization process for behavioral health conditions in MCS system for approved authorizations and notifications, including preservice
    • Receive and process requests for continued stay or additional treatments, as necessary
    • Contact hospitals, physicians or ancillary providers where additional information is necessary to make a decision
    • Completes faxing, attaching and documenting assessment results at every initial ad concurrent review
    • Consult with Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval
    • Performs initial medical necessity triage screening and concurrent or pre-service review on utilization management functions as assigned
    • Shares team telephonic crisis and clinical after hours duties as assigned
    • Ensure timeliness of decisions for BH requests
    • Participates in BH afterhours rotation including nights and weekends for crisis calls and authorizations
    • Plans discharges/transfers to ensure appropriateness and continuity of care
    • Participates in QIA activities and adheres to all NCQA, URAC or general accreditation  and state Medicaid guidelines and standards
    • Consistently demonstrates compliance with HIPAA regulations, professional conduct and ethical practice
    • Participate in discharge planning of members with psychiatric disorders to support MHP outreach efforts to improve Healthcare Effectiveness Data Information Set (HEDIS) measures and Provider Services Network Activities
    • Prepares denial letters for denied inpatient psychiatric admission
    • Enters authorizations for behavioral health services and addresses continuity of care issues for any applicable lines of business
    • Make referrals as indicated to Care Coordination
    • Complete letters and forms for submission of requests as needed
    • Notifications: SASS (including follow up), intensive outpatient program
    • Coordinate with denials team to create and fax/ mail denial letters for members and providers as required and within established timeframes
    • Ensure that approved requests are faxed back to appropriate hospital, physician or ancillary provider offices
    • Follow appropriate NCQA and State-specific regulations, as conducted by BH Case Management staff
    • Identifies members for case management
    • Performs post inpatient calls to members


    What you can bring to Meridian:

    • Current licensure and Master’s Degree in Social Work or related mental health field is required
    • A minimum of 2 year case management experience
    • Three years mental health experience with clinical background is required
    • Must possess working knowledge of Behavioral Health utilization review, clinical levels of care, Public sector mental health, NCQA, state specific mental health codes and regulations

    What Meridian can offer you:

    • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.


    Equal Opportunity Employer



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